Internet Mental Health Given Name: Renee Date: 05/22/1996 Sex: Female Marital Status: Never Married Age:

18 Residential Status: At Home Occupation: Student

Quality of Life Scale

How is your physical health? 1. Vigorous Physical Exercise: 2 2. Physical Mobility: 0 3. Pain or Discomfort: 0 4. Fatigue: 1 5. Sleeping Problem: 1 6. Appetite or Eating Problem: 0 7. Sexual Problems: 0 8. Seeing or Hearing Problems: 0 9. Overall Physical Health: 0 Are you happy with people in your life? (Spouse/romantic partner, family, friends) 10. Family Problems: 1 11. Friendship Problems: 1 12. Mistrust: 1 Do you need help to live independently? 13. Problems Living Independently: 0 How is school going? 14. Educational Problems: 3 Are you happy with your work? 15. Occupational Problems: N/A (Unemployed, No Volunteer Work) How is your housekeeping going? 16. Housekeeping Problems: 3 How are things going financially? 17. Economic Problems: 0

Are you happy with where you live? 18. Housing Problems: 0 What do you do for fun or excitement? 19. Reckless Thrill-Seeking: 1 Any problems with the law? 20. Disrespect For The Law: 0 Do you ever get into physical fights? 21. Physical Violence: 0 Do you smoke? 22. Smoking: 0 Do you ever get drunk? 23. Alcohol Abuse: 0 Do you ever get intoxicated on drugs? 24. Drug or Medication Abuse: 0 Any problems with fear or panic? 25. Agoraphobia: 1 26. Other Phobia: 0 27. Panic Attacks: 0 Any obsessions or compulsions? 28. Obsessions or Compulsions: 0 Any depressed mood? 29. Depressed Mood: 0 Any persistent anxiety or worry? 30. Generalized Anxiety: 0 Any problems with anger? 31. Anger: 0 Or guilt? 32. Guilt or Shame: 0

Ever think of harming yourself (or others)? 33. Self-Harm: 0 Were you ever so happy, excited, or over-talkative that it caused problems? 34. Elated Mood: 1 35. Over-Talkative or Racing Speech: 0 Were you ever agitated or hyperactive? 36. Hyperactivity: 0 Did you ever have unusual beliefs or experiences that others found hard to believe or understand? 37. Grandiosity: 0 38. Reality Distortion: 0 39. Conceptual Disorganization: 0 Any problems with your thinking or communication? 40. Distractibility: 2 41. Apathy: 2 42. Forgetfulness: 3 43. Impaired Executive Functioning: 3 44. Impaired Social Communication: 3 45. Bizarre Behavior: 0 46. Personal Neglect: 0 47. Psychomotor Slowing: 0 48. Confusion: 0 Were you in hospital (or institutional care)? 49. Institutional Care: 0 Did you want help for your problems? 50. Insight: 0 Overall how was your life going? 51. Overall Life Functioning: 3 How confident and optimistic were you? How independent as assertive were you? 52. Self-Confidence: 1 53. Optimism: 1 54. Belonging: 1

55. Independence: 1 56. Assertiveness: 1 57. Peacemaking: 1 How loving, friendly, and outgoing were you? 58. Intimacy: 1 59. Sociability: 1 60. Emotional Expressiveness: 0 How ordered or chaotic was your life? 61. Moderation: 1 62. Work-Life Balance: 0 63. Flexibility: 0 64. Genuineness: 0 65. Chastity: 0 66. Caution: 0 67. Emotional Stability: 1 68. Stable Self-Image and Life Goals: 1 69. Stable Personal Relationships: 1 How trusting, generous, and responsible were you? Any lying, stealing, or cheating? 70. Trust: 1 71. Forgiveness: 0 72. Gratitude: 0 73. Humility: 0 74. Cooperation and Generosity: 1 75. Kindness: 0 76. Respect: 1 77. Responsibility: 1 78. Honesty: 0